Flourishing through the Virtue of Courage in Healthcare

Purpose: The purpose of this study was to explore level of moral distress, moral sensitivity, and ethical climate of nurses working in psychiatric wards and identify factors that influence moral distress. Also this study was done to describe the content of moral distress. Methods: Data were collected through self-report questionnaires and focus group interviews. A survey was conducted with 108 psychiatric nurses and 8 volunteers were interviewed. Instruments used in this study were the Moral Distress Scale for Psychiatric Nurses, Korean version of the Moral Sensitivity Questionnaire, and Ethical Climate Questionnaire. Data were analyzed using SPSS/WIN 20.0 program and content analysis. Results: The mean score for moral distress was 3.74 and for moral sensitivity, 4.67. The significant factors influencing moral distress were clinical career in psychiatric wards, moral sensitivity, personal profit and friendship. As a result of content analysis, 3 domain of moral distress were found: moral distress situations, responses in moral distress situations, factors to overcome moral distress and resources that enable ethical nursing. Conclusion: The results suggest that in the development of interventions to decrease moral distress for nurses working in psychiatric wards, factors identified as influencing moral distress and content of moral distress should be considered.

Ethics education based upon everyday ethical dilemmas can help trainees place themselves within the situation and encourage them to reflect on their role and responsibility in reaching its resolution.• Three elements can help augment the bioethics teaching experience: (a) identifying the ethical dilemma, (b) employing methods of ethical analysis, and(c) having knowledge of additional bioethics resources.An increasing number of bioethics resources are available to clinicians, including clinical ethics consultation (CEC) and print and Web-based resources.

In the insightful and provocative book Final Exam, noted author and liver transplant surgeon Pauline Chen chronicles her medical education and some of the ethical dilemmas physicians face in practice. (1) describes a hierarchal and often authoritative system of care, reflecting upon the frailties of care providers as well as patients. Though she does not explicitly use the term, Chen implicitly describes the impact of moral distress on health care quality, providers' ability to meet professional and ethical obligations, and subsequent provider satisfaction and retention. Moral distress, as defined by Andrew Jameton in 1984, is the inability of a moral agent to act according to his or her core values and perceived obligations due to internal and external constraints. (2) Others have noted the psychological and physical burdens resulting from moral distress. (3) Today, nurses and their colleagues face ethical issues that seem more complex and more frequent than when Jameton coined the term twenty-five years ago. Although moral distress was originally conceptualized to address ethical issues in nursing, all health care professionals tackle morally relevant questions pertaining to the rightness or wrongness of decisions, treatments, or procedures, while feeling powerless to change situations they perceive to morally wrong. Providers frequently say things like, It's not my job to speak out; no one will listen anyway, or, doesn't make any sense; why are we continuing to do this?, or want to tell the patient to run. A case drawn from practice shows the anger, guilt, and moral compromise that health care professionals may experience in situations of moral distress. A thirty-five-year-old woman, Ms. Adams (all names and identifying details have been changed), had been diagnosed with acute lymphocytic leukemia that proved resistant to all standard and experimental chemotherapy regimens. was divorced, uninsured, and had four young children. Previously hospitalized for fungal pneumonia and sepsis that was compounded by a low white blood cell count from experimental treatment, Ms. Adams returned to the emergency room with abdominal pain, nausea, and vomiting. was readmitted and diagnosed with a pancreatic abscess and small bowel obstruction; she developed intractable pain and pancytopenia--a form of anemia requiring daily transfusions. was not a candidate for surgery at this time because of her debilitation. Ms. Adams and her family met with the team to discuss her options. refused hospice care in lieu of continuing aggressive treatments like experimental chemotherapy, believing that she would be healed and pull through this ordeal. said that after her blood counts recovered, she wanted to go home to spend time with her children. chose to remain a full code rather than agree to a do-not-resuscitate order. Her parents told the oncology fellow, She is a fighter and would want to try anything to save her life. Jane, Ms. Adams's primary nurse, struggled to accept these decisions. had already seen several primary care patients suffer through medically futile chemotherapy. Jane empathized with her patient's desire to keep fighting for her children, but she doubted Ms. Adams would leave the hospital alive. A week later, Ms. Adams again developed sepsis, along with blood in her urine, confusion, rapid breathing, and system failure. Jane asked, Why are we providing false hope to Ms. Adams and her family? This seems senseless. I feel like I'm inflicting unnecessary suffering on her. The fellow agreed, saying he was also troubled and would not choose this type of treatment for himself or his loved ones. He believed hospice would the best option for Ms. Adams, but told Jane that his job was to do everything he could to keep her alive, since he must follow his attending physician's orders and the family's wishes. Ms. Adams died two weeks later in the intensive care unit, never making it home to see her children. …

Many of the major challenges facing educational leaders involve leadership in situations where values and ethics are contested (Duignan & Collins, 2003). Some of these challenges constitute what Wildy et al . (2001) call ‘contestable values dualities’, or ‘ethical dilemmas’ (Dempster, 2001). ‘Dilemma’ usually indicates a difficult and challenging situation that, according to the Concise Oxford dictionary (1984, p. 268) ‘leaves only a choice between equally unwelcome possibilities’, and the example they provide is ‘on the horns of the dilemma’. However, the majority of the challenges discussed in this chapter represent situations where there are more than two alternative possibilities; in fact most of the challenges are multidimensional in nature. In this book, the word ‘tension’ is preferred to ‘dilemma’ to describe these situations, because it denotes that relationships exist between a number of ‘contestable values dualities’ and that the different possible solutions for each situation will reflect how these relationships are balanced. This approach has profound implications for the ways in which educational leaders respond to difficult and challenging situations. A more complete explanation of why it is best to treat a difficult and challenging situation as a tension is discussed in chapter 4. The ‘real challenges’ of educational leadership – the ones that keep educational leaders awake at night, cause them to take stress leave or retire before their time – are tensions between and among people, especially those based on philosophies, values, interests and preferences.

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and responsibilities in situations of moral distress. We also discuss the importance of nurses creating "counterstories" of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life.

Moral distress is a significant stressor for nurses in critical care. Feeling that they are doing the "right thing" is important to nurses, and situations of moral distress can make them question their work. The purpose of this study was to describe critical care nurses' levels of moral distress, the effects of that distress on their personal and professional lives, and nurses' coping strategies. The study consisted of open-ended questions to elicit qualitatively the nurses' feelings about moral distress and a quantitative measure of the degree of distress caused by certain types of situations. The questionnaires were then analyzed to assess the nurses' opinions regarding moral distress, how their self-perceived job performance is affected, and what coping methods they use to deal with moral distress. The most frequently encountered moral distress situations involved critically ill patients whose families wished to continue aggressive treatment when it probably would not benefit the patient in the end.

Objectives – In recent years, moral distress has become a topic of interest among health professionals. Moral distress is most commonly described in the nursing literature, and refers to a situation wherein an individual knows the correct action to take, but is constrained from doing so. While moral distress differs from the classic ethical dilemma, in recent years practitioners and theorists have advocated for a broadening of the definition of moral distress. To date, no study has examined another group of individuals who frequently interact with patients and who may be constrained by the confines of their role - Consumer Health Information Professionals (CHIPS). The objective of this study was to determine if CHIPS experience moral distress and/or ethical dilemmas, and to determine what, if any, coping strategies these individuals have developed. Methods – This study employed a mixed methods approach. Quantitative data were gathered via an online survey which was distributed to relevant consumer health information professional electronic mail lists. The survey contained demographic questions and a series of questions related to potential discomfort within the context of work as a consumer health information professional. Qualitative data were also gathered through phone interviews with CHIPS. Interview questions included the participant’s definition of moral distress, professional experiences with moral distress, and any coping strategies to manage said distress. Results – The authors received 213 survey responses. To test whether any of our demographic variables help to explain survey response, we used STATA to calculate Pearson correlation coefficients. Individuals who were more likely to experience discomfort in their occupation as CHIPS included individuals with less experience and individuals who identified as Black and Latinx. Interview data indicated that participants most commonly experienced ethical dilemmas related to censorship, providing prognosis information, and feeling constrained by institutional policies. Few interview participants described scenarios that reflected moral distress. Conclusions – CHIPS do not appear to experience moral distress, at least according to its most narrow definition. CHIPS do consistently experience distinct ethical dilemmas, and the most durable patterns of this phenomenon appear to be related to experience level and racial identity. In recent years, researchers have raised calls to broaden the definition of moral distress from its narrow focus on constraint to include uncertainty, and CHIPs do experience moral uncertainty in their work. Further study is needed to determine how to best address the impacts of discomfort caused by ethical dilemmas among these groups.

To propose two NANDA diagnoses--ethical dilemma and moral distress--and to distinguish between the NANDA diagnosis decisional conflict and the proposed nursing diagnosis of ethical dilemma. Journal articles, books, and focus group research findings. Moral/ethical situations exist in health care. Nurses' experiences of ethical dilemmas and moral distress are extrapolated to the types and categories of ethical dilemmas and moral distress that patients experience and are used as the basis for development of two new nursing diagnoses. The two proposed NANDA diagnoses fill a void in current standardized terminology. It is important that nurses have the ability to diagnose ethical or moral situations in health care. Currently, NANDA does not offer a means to document this important phenomenon. The creation of two sets of nursing diagnoses, ethical dilemma and moral distress, will enable nurses to recognize and track nursing care related to ethical or moral situations.

Nurse moral distress: A survey identifying predictors and potential interventions

Nurse managers are placed in a unique position within the healthcare system where they greatly impact upon the nursing work environment. Ethical dilemmas and moral distress have been reported for staff nurses but not for nurse middle managers. To describe ethical dilemmas and moral distress among nurse middle managers arising from situations of ethical conflict. The Ethical Dilemmas in Nursing-Middle Manager Questionnaire and a personal characteristics questionnaire were administered to a convenience sample of middle managers from four hospitals in Israel. Middle managers report low to moderate levels of frequency and intensity of ethical dilemmas and moral distress. Highest scores were for administrative dilemmas. Middle managers experience lower levels of ethical dilemmas and moral distress than staff nurses, which are irrespective of their personal characteristics. Interventions should be developed, studied, and then incorporated into institutional frameworks in order to improve this situation.

BackgroundWorldwide, nurses have been at the frontline of the Covid-19 pandemic response and central to its effectiveness. They faced numerous ethical dilemmas which in turn resulted in considerable moral distress. However, there are knowledge gaps on the experiences of critical care nurses in South Africa during the pandemic.AimExplore the experiences, specifically the ethical dilemmas and moral distress, of critical care nurses working in South African hospitals.MethodsGilligan’s ethic of care theory informed this exploratory, qualitative descriptive study with nurses who had experience of taking care of individuals with Covid-19 and working in intensive (critical) care units in the Gauteng province of South Africa. We recruited eligible nurses through a combination of social media adverts, snowballing, and referral from professional associations or trade unions. Following voluntary informed consent, we conducted in-depth interviews with nurses using an interview guide that focused on personal and professional experiences during the pandemic, ethical dilemmas, relationships with other colleagues and/or management, and the availability of support systems. Data was analysed thematically.ResultsThe participants comprised 21 nurses, 16 females and 5 males with a mean age of 38 years. The majority were professional nurses (20/21 = 95%) and from the public health sector (17/21 = 81%). Nurses highlighted the tension between their deep caring for patients and the realities of taking care of patients during the Covid-19 pandemic that necessitated pragmatic compromises, such as doing the bare minimum. They expressed ambivalence about the Nursing Oath because they were acutely aware of the moral obligation to put the health of their patients as their first consideration, yet they faced the personal risk of infections and disease exposure. The uncertainty and fear of the pandemic, of infection, of the unknown, and of being in the frontline of health care provision resulted in considerable moral distress. Simultaneously, the perceived lack of appreciation for their work and for risking their lives as health care providers, and the resource constraints intersected with and exacerbated both ethical dilemmas and moral distress.ConclusionsThis study highlights the ethical dilemmas that nurses experienced during the pandemic, and their perceived moral distress. It contributes to the discourse on healthcare ethics, particularly in crisis situations, and highlights the need for robust support systems for nurses.

To identify themes and gaps in the literature to stimulate researchers to develop strategies to guide decision-making among clinical nurses faced with ethical dilemmas. The concept of ethical dilemmas has been well explored in nursing because of the frequency of ethical dilemmas in practice and the toll these dilemmas can take on nurses. Although ethical dilemmas are prevalent in nursing practice, frequently leading to moral distress, there is little guidance in the literature to help nurses resolve them. This study is an integrative review of published research from 2000 to 2017. The keywords ethics, ethical dilemmas and nurs* were searched in CINAHL, PubMed, OVID and SCOPUS. Exclusion criteria were sources not available in English, not in acute care, and without an available abstract. Seventy-two studies were screened; 35 were retained. Garrard's matrix was utilised to analyse and synthesise the studies. Ethical dilemmas arose from end-of-life issues, conflict with physicians or families, patient privacy concerns and organisational constraints. Differences were found in study location, and yet international research confirms that ethical dilemmas are universally prevalent and must be addressed globally to protect patients and nurses. This review offers an analysis of the available evidence regarding ethical dilemmas in acute care, identifying themes, limitations and gaps in the literature. The gaps in quantitative intervention work, US paucity of research, and lack of comparisons across practice settings/nursing roles must be addressed. Further exploration is warranted in the relationship between ethical dilemmas and moral distress, the significance patient physical appearance plays on nurse determination of futility, and strategies for pain management and honesty. Understanding and addressing gaps in research is essential to develop strategies to help nurses resolve ethical dilemmas and to avoid moral distress and burnout.

To describe surgical nurses' perceived levels of ethical dilemmas, moral distress and perceived quality of care and the associations among them. Nurses are committed to providing quality care. They can experience ethical dilemmas and moral distress while providing patient care. Little research has focused on the effect of moral distress or ethical dilemmas on perceived quality of care. Descriptive, cross-sectional study. After administration and institutional Research Ethics Committee approval, a researcher requested 119 surgical nurses working in two Israeli hospitals to fill out three questionnaires (personal background characteristics; Ethical Dilemmas in Nursing and Quality of Nursing Care). Data collection took place from August 2007 to January 2008. Participant mean age was 39·7 years. The sample consisted mostly of women, Jewish and married staff nurses. The majority of nurses reported low to moderate levels of ethical dilemma frequency but intermediate levels of ethical dilemma intensity. Frequency of ethical dilemmas was negatively correlated with level of nursing skill, meeting patient's needs and total quality of care. No important correlations were found between intensity of ethical dilemmas and quality of care. Levels of ethical dilemma frequency were higher than intensity. Nurses tended to be satisfied with their level of quality of care. Increased frequency of ethical dilemmas was associated with some aspects of perceived quality of care. Quality of care is related to ethical dilemmas and moral distress among surgical nurses. Therefore, efforts should be made to decrease the frequency of these feelings to improve the quality of patient care.

Experiences of moral distress in nursing students – A qualitative systematic review

The nurse's moral competences in the management of situations which present ethical implications are less investigated in literature than other ethical problems related to clinical nursing. Phenomenology affirms that emotional warmth is the first fundamental attitude as well as the premise of any ethical reasoning. Nevertheless, it is not clear how and when this could be confirmed in situations where the effect of emotions on the nurse's decisional process is undiscovered. To explore the processes through which situations of moral distress are determined for the nurses involved in nursing situations, a phenomenological-hermeneutic analysis of a nurse's report of an experience lived by her as a moral distress situation has been conducted. Nursing emerges as a relational doctrine that requires the nurse to have different degrees of personal involvement, the integration between logical-formal thinking and narrative thinking, the perception of the salience of the given situation also through the interpretation and management of one's own emotions, and the capacity to undergo a process of co-construction of shared meanings that the others might consider adequate for the resolution of her problem. Moral action requires the nurse to think constantly about the important things that are happening in a nursing situation. Commitment towards practical situations is directed to training in order to promote the nurse's reflective ability towards finding salience in nursing situations, but it is also directed to the management of nursing assistance and human resources for the initial impact that this reflexive ability has on patients' and their families' lives and on their need to be heard and assisted. The only case analysed does not allow generalizations. Further research is needed to investigate how feelings generated by emotional acceptance influence ethical decision making and moral distress in nursing situations.